This is pretty outrageous, and I think, an abuse of process. Let me elaborate from my point of view as an Emergency department nurse. In the course of any shift I may give advice and education on:

wound care and dressing changes — but I am not a nurse specialist on wound care and dressings

casts and splints — but I am not a specialist in orthopaedic nursing

diet for cases of gastroenteritis — but I am not a dietitian

prescriptions — but I am not a pharmacist

preparation for diagnostic imaging — but I am not a radiography tech

advise first time pregnancies on the benefits of breastfeeding — but I am not a lactation nurse

head injury routine — but I am not a nurse specialist in neurology

treatment of fever in children — but I am not a paeds nurse

Now according to the Arizona State Board of Nursing, I am representing myself as a specialist in all of these areas, and probably a few score more that I haven’t listed. By the considered, professional judgement of the nursing leadership inhabiting the halls of the Arizona State Board of Nursing, I should just shut up, because I am clearly qualified to do squat.

The Arizona State Board of Nursing evidently believes nurses educating patients on anything is beyond their scope of practice. And by extension, nurses educating patients puts patients in danger.

Ridiculous?

Absolutely. And this is why this latest charge is a trumped-up nonsense. Nursing as a profession would cease to exist in Arizona if nurses had to meet the stringent requirements the BoN now apparently requires, if nurses need some sort of official certification as “specialist” before providing education of any sort. The “position” now put forward by the Board of Nursing is contradicts widely accepted nursing practice. Providing health teaching is the standard of care around the world. This is what nurses do. In my jurisdiction, you can be disciplined for not providing appropriate education.

Jennifer Olin puts it this way:

This just makes no sense. Trujillo may be interested in end-of-life issues, she admitted herself that she had provided such information to patients previous to the one involved in this incident with no objections from physicians or hospital management. In fact, that evening, she even cleared her plan of care with the clinical manager.

This is not claiming to be a certified specialist. We are nurses. We are expected to know quite a bit and, more importantly, how to find information for our clients and ourselves. The information Trujillo provided was pulled straight from the information banks of the hospital’s own computer system.

Exactly. This is what we know as nurses. We educate. To claim otherwise is to run against the experience and practice of millions of fully qualified and competent nurses. The Arizona Board of Nursing knows this too. They are nurses, after all. You can only conclude the Board is grasping at straws at this point, hoping to harass or intimidate Trujillo into submission.

The next step is an evidentiary hearing, for which the Board of Nursing has not yet set a date. As of next month it will be a year since this business started. The wheels of justice grind slowly, it’s said. Let’s just hope they grind as finely as advertised.

One more note: I spoke at length with Amanda yesterday, and she is very well and in good spirits. Her lawyer has asked her not to comment publicly further on her case, so I can’t relay what she told me. However, I will say the story grows more convoluted by the day and there is far more going on than can be publicly mentioned. So stay tuned!

For the past month, the case of Amanda Trujillo has resonated deeply among nurses, triggering an avalanche of postings on Facebook, Twitter and in the nursing blogosphere. Trujillo is the Arizona nurse who was fired in April 2011 after providing education and making a hospice care consult request for an end-stage liver disease patient. This patient was slotted for pre-transplant evaluation and had poor understanding of the disease process and treatment options. Trujillo filled in the gaps for this patient. Trujillo then requested, at the patient’s own wish, a hospice team consult, documented her actions appropriately, and left a note (it was night shift) for the primary physician.

These actions — the education and the hospice team consult — drew the wrath of both the primary physician, who demanded her dismissal and her license, and also her nursing director, who told Trujillo she had “messed up all the doctors’ hard work and planning for the surgery.” The patient-requested hospice care consult was cancelled. Trujillo’s employer subsequently fired her, and reported her to the Arizona State Board of Nursing for exceeding nursing scope of practice, though in fact, nurses previously had ordered a hospice care consult without consequence. In short, many nurses believe Trujillo was fired for educating and advocating for her patient.

These are the bare bones of the story. (Further details can be found here and here.) The debate among nurses — sometimes heated — has common themes around the limits of nursing practice, the meaning of nursing advocacy, and how nurses in trouble are left high and dry by the professional organizations that purport to represent them. Well and good. But why should physicians care?

Before I answer that question, let me tell you about my own practice as a nurse in a busy Toronto Emergency department. I work shoulder-to-shoulder with some of the best physicians I have ever known. Our goal is give excellent care and treatment to every patient we see. In order to do this job well and effectively, I need some tools — like the freedom to educate and advocate for my patients — and recognition that my judgement and accountabilities as a nurse are quite separate, if related, to those of physicians.

More importantly, I need the confidence to know I can engage in collaborative practice — and this in not just a one-way street, by the way — with my physician Emergency department colleagues. This is not a theoretical proposition, incidentally. If I tell an ED physician, for example, that a patient’s needs are largely social, and I have arranged for social work, and if she discounts or minimizes my concerns, and cancels the referral, then the patient suffers in the end. If I tell her that in my nursing judgement, the patient is crashing, and she ignores me, the patient dies. Being an effective patient advocate and practising collaboratively with physicians (and patients too, I might add) is good patient care. Yet doing my job well is precisely the same sort of advocacy which got Amanda Trujillo fired and reported to the Arizona State Board of Nursing.

Physicians should be concerned about Amanda Trujillo for this reason: ultimately her case is about providing good patient care. There are, of course, obvious serious issues about patient autonomy and the ability of hospitals and physicians to override patient decisions about their own care. Many physicians might sympathize with Trujillo’s arbitrary firing, or see in her case a reflection of their own professional concerns about the role of large health corporations in their day-to-day practice.

But for me, as a nurse, the issue boils down to whether the health care industry can tolerate highly educated, vocal, critically-thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with — and challenge, if necessary — physicians and established treatment plans. Or does the industry just want robots with limited analytical skills who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?

Yes, I’m going to say it: Forget advocating. Be humble. Be honest and consistent. Go through the process. Listen to your attorney. Your most important asset as a terminated person is an unrestricted nursing license and lack of bitterness. Get advice from your attorney and mentors about what to say in job interviews about your termination. Rehearse your answers to the question of “why were you terminated from Banner Health.” Don’t decide that you’re never working for a hospital again and you don’t care what anyone thinks. You’re a single mom on welfare with a termination on your record; you don’t have the luxury of being picky.

This termination was not about who can order a case management consult. This was the typical crap that I saw every day. Someone important (in this case, the surgeon who was to perform the transplant) [it was a gastroenterologist, not the transplant surgeon, incidentally — ed.] looks bad or is pissed at someone for something and demands a termination and the thing spirals out of control.

This type of stuff is a hospital culture problem and certainly needs to stop, but a terminated employee is not going to stop anything like that, so don’t expose yourself to the world as a fired person with a chip on their shoulder.

Well, fair enough. You pick your battles. What she’s suggesting is that for Amanda Trujillo, maybe this wasn’t the hill to die on. This is true in some, maybe even most, cases. It is excellent advice, in fact. I have a friend whose employer reported her to the College of Nurses of Ontario — the semi-equivalent of state boards of nursing — for a serious med error that contributed to the death of a patient. She went through the process, humble and contrite, and received a formal written caution and oral reprimand. Her employer supported her through her rehabilitation, worked out a mentorship and learning plan with her; she took a refresher course on medication. She is still practicing. This is how the system is supposed to work, right?

To paraphrase Queen Victoria, just lie back and think of Florence. I don’t think I am caricaturing Nurse K’s position here, not much anyway. Most times, silence is golden and discretion is the better part of valour, and all those other platitudes your mother taught you.

But then, this isn’t a conventional case. Let’s review for minute: Trujillo offers a patient information regarding an organ transplant and arranges, as per usual practice and at the patient’s request, a hospice care consult; this angers a physician; she is arbitrarily fired for exceeding her scope of practice in ordering this consult, which was inside her scope the day before; no one was harmed or put at risk, except, perhaps, the physician’s ego; Banner Health, Trujillo’s employer, reports her to the Arizona State Board of Nursing for practicing outside scope of practice which — I can’t say this enough — was practicing inside scope of practice the day before; the case languishes for months and months in some sort of bizarre Board of Nursing limbo; then the moment Trujillo’s case caught the attention of some ratty-end nurse bloggers, the Board of Nursing orders a psych consult, evidently because publicly defending yourself makes you crazy; the Board of Nursing subsequently (and in a highly dubious fashion) informs Trujillo’s university she’s under investigation, then denies it despite clear proof to the contrary; and now the latest buffoonery, a new accusation from the Board of Nursing that Trujillo has “misrepresented” herself as to her academic credentials.

If this is a typical case, we are all in trouble.

And there’s this observation: isn’t shutting up and going away what employers and managers and nursing boards expect front line nurses to do? Don’t make trouble, nurses. It’s unbecoming. It will just make things worse — yes, for you. Don’t advocate for yourself — because — we will call you crazy. You will be screwed over — and you will like it!

The thing is, even before all the fuss, it’s hard to imagine how this could have gotten worse for Amanda Trujillo. If the fix is in, if you’re being railroaded by your employer, and the state Board of Nursing (as Nurse K says) is shady and duplicitous, being demure and helpful and willing to take your lumps is not going to help you. And why in the name of everything that is sacred and good should you help someone who is seeking to harm you? And as for meekness and docility now? Seems rather besides the point now.

In any case, nurse as silent martyr is not a great image. Nurse as battered wife is worse. Advocacy for yourself, and for your profession is sometimes not one of many bad choices, it is the only choice. Because of circumstances yes, but also because it is right. And as Nurse Ratched points out, often it only takes one pebble to start an avalanche.

Notions to small for a blog post, all in one place, a.k.a. the periodic link dump.

Giving all aid short of actual help. First, some words from the American Nurses Association on Amanda Trujillo. The ANA finallyissued a news release, in which they absolutely avoided, like nervous grannies dithering over an icy stretch of sidewalk, any position at all. However, they are watching the case “closely.” They advise “nurses and the public not to rush to judgments about complex cases based on social media postings or other media coverage.” They tell nurses in trouble to avail themselves of the “many resources available on its website”. That’s pretty well it. Three Tweets and they could have saved themselves 323 words and a news release. Would have been a more honest display of actual content, too.

So what about Pinterest, anyway? Got my account, and am still puzzled by what exactly to do with it. (Though got a recipe for Olive Garden Alfredo Sauce.) HealthisSocial has some answers, but may also be mocking you.

The complaints are even more surprising given the culture of nursing. Rarely having time for rest and meal breaks is part of the nursing folklore. New graduate initiation practically stipulates that a requirement of successful floor nurses is a gargantuan bladder.

This culture is entrenched. A 2004 study published in the Journal of Nursing Administration revealed that hospital staff nurses were completely free of patient care responsibilities during a break or meal period less than half the shifts they worked. In 10%

of their shifts, nurses reported having no opportunity to sit down for a break or meal period. The rest of the time, nurses said they had time for a break, but no one was available to take over patient care

The case of Amanda Trujillo has generated a great deal of passionate commentary across the nursing blogosphere. Trujillo, as you may well know, is the nurse who was fired by Banner Health Del E. Webb Medical Center for requesting multi-disciplinary hospice care case management consult for a pre-transplant patient with end-stage liver disease. The request angered the patient’s physician — not the transplant surgeon, incidentally, nor someone with any knowledge of transplant surgery — who complained to Trujillo’s manager. After her termination, the hospital subsequently reported her to the Arizona State Board of Nursing for exceeding her scope of practice. If the Board finds against Trujillo, she may well face the loss of her license or other sanctions; in the event, her nursing career would be finished. Superficially, at least, an open and shut case, or least this is how Banner Health would like to project the controversy. Scratch the surface a little and matters change considerably.

So why are nurses so furious? Part of it is the apparent coincidence of any number of other, seemingly random bits of information outside the direct narrative of Trujillo’s story. The fact that the Arizona State Board of Nursing chose to deem Trujillo’s attempt to defend herself publicly as “retaliatory behavior” just as her story was becoming part of the general conversation, and then ordered a psychiatric evaluation is one of those seemingly random bits. This struck me particularly. Suspicious minds might see a pattern to punish Trujillo for speaking up by publicly labelling her mentally disturbed (and in health care, as any nurse will tell you, acquiring that label is doubly damning.) For myself, I will be content to note that throughout history calling people crazy is a traditional means of discrediting those challenging authority and marginalizing dissent.

And there are other random bits: that the Arizona Board of Nursing (for example) chose to inform Trujillo’s doctoral program of the ongoing investigation just last week — some ten months after the initial complaint. The apparent close linkages between various facets of the nursing “leadership” in Arizona, which I am told is known as the “Circle of Death” for woe to any nurse who crosses it. The secrecy, the opacity of all the institutional players, from Banner Health to the Arizona Nurses Association. The sense of arbitrary and coercive behaviour from any of these. Separately, they don’t amount to much — but together? Suspicious minds, as I said, begin to see patterns.

But there are far more substantive issues the firing of Trujillo raises. Take, for example, the matter how and why Trujllo was fired. From Trujillo’s account, it was arbitrary and unjust. Trujillo acted, she says, in good faith; her intent was to help the patient make an informed choice about his treatment options; she had made the same request for similar cases previously without consequence or objection; there was no hospital policy positively forbidding nurses to make this request. The only difference, it appears, was the physician’s annoyance, that as Trujillo’s manager put it, Trujillo had “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”

So there is this, a manager’s buckling under physician pressure, to do something about this turbulent nurse, a nurse who was trying to conscientiously to do her duty —- which happened to conflict with the plans of the physician. But that is not even the really bad part. Let me put it in this way by citing an example that has weighty consequences for both nurse and patient. If nurse commits a serious medication error, best practice anywhere is for the hospital administration to do a root cause analysis. The purpose of this analysis is not to apportion blame, but to prevent the error from ever happening again.

Once the root cause is determined, there might be changes to existing policies and procedures, and there might be education. Almost always, there is some sort of remediation of the nurse involved, because responsibility for a medication error is ultimately a shared responsibility from the nurse who administers the medication to the senior managers who are responsible for policies ensuring patient safety. For Trujillo, there was none of this — just security escorting her off the premises.

A reasoned, measured response to Trujillo’s actions, using root cause analysis, might suggest change and clarification of existing procedure for ordering case management consults. Instead, we have a nurse whose offence is so grievous that the hospital chose to fire her and then report her to the state Board of Nursing. To put it another way, even if Trujillo was completely in error in her interaction with this patient, and exceeded her scope of practice, what exact demonstrable harm was done to the patient?

I am puzzled why a clerical error — which I think is the worst possible cast one could put on Trujillo’s actions — merits termination and Board of Nursing discipline, while a serious medication error generally would not. It’s the gross inequity of outcomes which is so troublesome. Please note, in this context, nurses are generally fired and reported to regulatory bodies when there is concern they are a danger to the public.

So you have to ask yourself this simple question: even if you accept Trujillo exceeded her scope of practice, was firing her and then reporting her to the Board of Nursing proportionate to the supposed misdemeanour? Acting rashly, inequitably, without reason, and disproportionately, to my way of thinking anyway, is central to any definition of arbitrary and unjust behaviour.

We are also angry that Trujillo apparently was penalized for acting as her patient’s advocate and for attempting to ensure her patient could act with autonomy. This has serious implications for all nurses, because hobbling any nurse’s ability to act as advocate seriously jeopardizes patient care and safety. But first, the word “advocate” has been bandied about so much I want to inject a little clarity as to what exactly nurse-as-advocate means in the context of end-of-life care. This is what my own regulatory body, the College of Nurses of Ontario, says:

Nurses advocate for their clients and help implement their treatment and end-of-life care wishes. However, a client’s request to receive a treatment does not automatically bring with it the obligation for the nurse to provide the treatment. A nurse is not obligated to implement a client’s treatment wish if it has been determined that the treatment will not benefit the client and is therefore not a part of the plan of care.

The College — no slouches in the matter of nursing ethics, by the way — goes on to tell us that that nurses act as advocates by ensuring patients have informed consent when implementing multidisciplinary care plans and by (says the College)

acting on behalf of the client to help clarify the plans for treatment when:

the client’s condition has changed and it may be necessary to modify a previous decision;

the nurse is concerned the client may not have been informed of all elements in the plan of treatment, including the provision or withholding of treatment;

the nurse disagrees with the physician’s plan of treatment; and

the client’s family disagrees with the client’s expressed treatment wishes

I think this is fairly standard nursing practice anywhere, and how all of us understand advocacy, whatever the stage of life. It is needful to point out the College phrases its language as nurses “must” not “may.” In other words, advocacy is not optional part of nursing practice. And what about patient autonomy? One of the four pillars of health care ethics, patient autonomy is the right of all patients to make informed decisions about their care and treatment, and necessarily implies outcomes matter most importantly for the patient, not the health care team. Nurse advocacy, it hardly needs to be said, is an important part of ensuring a patient can act an informed autonomous way.

So we have a situation where Trujillo was practising under universally accepted nursing standards, using the nursing process and nursing judgement, made a nursing assessment, educated her patient, in order that the patient could make an informed decision about his treatment options; in short, she acted to preserve her patient’s autonomy, and then was punished in the worst possible way for her attempts to be, well, a good nurse. Here’s her account, drawn from her lawyer’s representation to the Arizona Board of Nursing:

Having assessed the knowledge deficit related to the patient’s routine medications, disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from Banner’s website that addressed those areas. . . Ms. Trujillo also provided materials related to hospice care per the patient’s request. Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s plan of care and interventions. . .

Ms. Trujillo and the patient reviewed the materials over the course of the night. After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.” The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries. Ms.Trujillo then explained hospice care services and the differences between symptom relief care and end of life care. The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.” The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice. She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in Banner policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation. She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.

I am not seeing a lot of daylight between a world-respected professional regulatory body’s standards of nursing practice and Trujillo’s actions. I personally would do no different. Which brings us to the exact point of what disturbs and angers so many nurses: when hospitals run roughshod over a nurse’s professional and ethical judgement, when they refuse to acknowledge a nurse’s central ethical duty to sustain patient autonomy, there does not seem to be any point to acting as a professionals at all. Or maybe, that’s the real message hospital corporations want to send: that front line nurses aren’t really professionals, and larger questions of ethics and patient care are better left to higher beings — physicians, corporate managers and our nursing “leadership.”

This is why we are passionate about Amanda Trujillo. This is why we are so angry. The issues raised by the Trujillo case affect each of us, because this is how we practice nursing. By keeping patients — their wants, desires, needs, autonomy — front and centre.

Advocates for Amanda Trujillo — and I include myself in that number — have been criticized for jumping the gun, for not waiting for the other side of the story, for surely Banner Health and all the rest will have their speak. I concede the point. I accept I may be wrong. Not all facts are apparent, and some will never come out. (By the same token I am not clear what further details are needed to come out in order to form a reasonable conclusion about the situation. This isn’t the Pentagon Papers, or use a more modern reference, a WikiLeaks cache dump.) My sense of the situation, however, is that Amanda Trujillo’s position is far nearer the truth.

I say this not because of the documentation, or because I have spoken to Trujillo about her case (and five minutes on the phone with was enough to convince me of her utter veracity), or because she makes herself readily available to her supporters — she spoke with me for over an hour last evening despite an exhausting day, and was able to answer with clarity some very probing questions — but because, sadly, her case follows the same pattern of abuse we have seen in other cases almost too numerous to count: arbitrary and vengeful behaviour from health care corporations, official investigations, attempts to discredit nurses and nursing and after a long time and huge financial and personal cost to nurse involved, vindication. And this is what frightens so many nurses: what happened to Trujillo and all the rest can easily happen to any of us, and in the process, chip away at our collective professional integrity. So a lot of us in the nursing blogosphere and through social media are determined to hold the feet of Banner Health, the Arizona Board of Nursing and all the rest to the fire. The fact so many of us are so vehemently engaged in this issue speaks volumes about our determination to uphold the integrity of our beloved profession.

Each of them eloquently speaks to the heart of what we do as nurses — and why nurses find how Amanda Trujillo was fired and subsequently reported to the Arizona State Board of Nursing so troubling. (Via The Innovative Nurse.)

Lastly Carol Gino. “The statement nurses eat their young — we’re not doing that. There’s a group of us who are going to stand with her. we’re not going to be powerless any more, because a defenceless defender is not good to anyone.”